ANNEXURE 1 Date: 2019/07

Document Number: S1 APCW

Application for a work permit to do construction work Page Number: Page 1 of 3
Revision Number: 2
Site: Contractor:

ANNEXURE 1
APPLICATION FOR A PERMIT TO DO CONSTRUCTION WORK
[In terms of Regulation 3(2) of Construction Regulations 2014]
This application must be submitted with the following documents:
1) Health and Safety specification.
2) Health and Safety plan.
3) Baseline risk assessment.

1. Name, postal address and telephone numbers of the client:

_______________________________________________________________________________________________
_____________________________________________________________________________
2. Details of the HTE Agent.
a) Title, Surname and Initials: _____________________________________
b) Identity number / Passport Number: _____________________________________
c) Registration number with SACPCMP: _____________________________________
d) Office Tel. number and/or Mobile Number : 082 4520 4420
e) Postal address: 10 Baobab Ave Roodekrans Roodepoort 1724

3. Name, Postal address and telephone numbers of the appointed principle contractor:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
4. Name, Postal address and telephone numbers of the designer of the project:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
5. Name, Postal address and telephone numbers of the following persons:
a) Construction Manager:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
b) Construction Health and safety manager:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
c) Construction Health and Safety Officer:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

6. Exact physical address of the construction site office:

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
NB! – The contents of this document is confidential, and Jan Hartzer holds the copyright of the entire document. Whilst every effort has been made to ensure that the
information published in this work is accurate, the author takes no responsibility for any loss or damage suffered by any person as a result of the reliance upon the information
contained therein. Printed copies are uncontrolled and may not be up to date.
 ANNEXURE 1 Date: 2019/07
Document Number: S1 APCW
Application for a work permit to do construction work Page Number: Page 2 of 3
Revision Number: 2
Site: Contractor:

7. Nature of construction work:

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
8. Expected commencement date:
_______________________________________________________________________________________________
9. Expected completion date:
_______________________________________________________________________________________________
10. Estimated maximum number of persons on the construction site:
_______________________________________________________________________________________________

11. Planned number of contractors on site accountable to principle contractor:

_______________________________________________________________________________________________

12. Name(s) of the contractors appointed:

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

13. ____________________________
Signature of Client/Client’s Agent

14. ____________________________
Signature of Principal Contractor

NB! – The contents of this document is confidential, and Jan Hartzer holds the copyright of the entire document. Whilst every effort has been made to ensure that the
information published in this work is accurate, the author takes no responsibility for any loss or damage suffered by any person as a result of the reliance upon the information
contained therein. Printed copies are uncontrolled and may not be up to date.
 ANNEXURE 1 Date: 2019/07
Document Number: S1 APCW
Application for a work permit to do construction work Page Number: Page 3 of 3
Revision Number: 2
Site: Contractor:

NB! – The contents of this document is confidential, and Jan Hartzer holds the copyright of the entire document. Whilst every effort has been made to ensure that the
information published in this work is accurate, the author takes no responsibility for any loss or damage suffered by any person as a result of the reliance upon the information
contained therein. Printed copies are uncontrolled and may not be up to date.